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eLetters

47 e-Letters

Dr. Biegler concludes that patient consent to a DNR order should be
required [1]. He rightly locates the reason for that ethical demand in
the principle of autonomy. If autonomy means anything, it must mean a
right to be involved in decisions about one’s own survival. It is also
correct to say that the law of consent, at least in common law
jurisdictions, is built on the philosophical foundation of au...

Dr. Biegler concludes that patient consent to a DNR order should be
required [1]. He rightly locates the reason for that ethical demand in
the principle of autonomy. If autonomy means anything, it must mean a
right to be involved in decisions about one’s own survival. It is also
correct to say that the law of consent, at least in common law
jurisdictions, is built on the philosophical foundation of autonomy [2].
Dr. Biegler seems to imply that consistent application of the principle of
autonomy would require the law of consent to agree with his conclusion
about DNR orders. But the law of consent is not the only law relevant to
the question of the requirement of consent to a DNR order. Also engaged is
the more general law governing a doctor’s duty to his patient. This is
painfully dislocated from the law of consent. Broadly, in UK law at least,
a doctor can choose when to assume a duty [3]. If he chooses to assume
that duty, the law of negligence swings into play and says what he has to
do in order to discharge it properly. But at almost any time the doctor
can wash his hands of the patient. That washing might get a doctor into
trouble with his employers or with the GMC: it will not get him into
trouble with the law of tort. The law of tort will not draft conditions of
employment.

If a doctor decides to assume a duty, the law tends to describe his
obligations in negative terms. It tells him that he must not do certain
things. Even when condemning commissions it uses negative language: such
and such a commission would amount to a dereliction of duty. Having been
brought up in the context of negligence, the law is almost totally
inarticulate in its discussion of positive duties. There is only one
arguable example of a positive duty: the duty to act in the best interests
of a patient who is unable to consent to the proposed treatment. The
deployment of the Bolam test [4] in ascertaining the patient's "best
interests" and determining the compliance of a doctor’s actions with those
"best interests", transmutes even this duty into something akin to the
ordinary obligation of not being a negligent doctor.

The relevance of the "best interests" criterion to the question of
consent to a DNR order is interesting and moot. At the time Dr. Biegler
says the consent should be taken, the patient is of course conscious and
presumably competent. That would suggest that no "best interests"
considerations arise at all. But at the moment when any resuscitation
attempt would occur, the patient would be unconscious. Then, conventional
legal wisdom would say, the only relevant consideration is that of "best
interests".

All this cannot cloak the legal reality. The corollary of Dr.
Biegler’s proposal is that a patient could require a doctor to resuscitate
him. (If Dr. Biegler would not go this far, then the requirement he is
talking about is not a requirement to obtain a patient’s consent to DNR at
all, but an obligation simply to discuss the issue, which is a very
different matter.) This would require radical exceptions to be made to
three fundamental legal principles. First: a patient would,
unprecedentedly in the law of tort, have to be able to force a doctor to
enter into a doctor-patient relationship and thereby assume a duty.
Second, the patient would have to be able to force the doctor to do a
positive act. And third, the doctor would have to be required to do
something to an unconscious patient which he did not believe was in the
patient’s best interests.

Those principles are there for a number of good reasons. If they are
eroded, there may be damage to the law a long way from the ICU.

In response to your interesting article I would thank you for raising
the issue of potential breach of confidence in relation to the teaching
of ethics.

I think what is missing from your account, from my perspective, is the
concept of members of OUR society being in this together. It is not
simply an issue which should be debated in the rather 'them-patients' and
'us-practitioners' manne...

In response to your interesting article I would thank you for raising
the issue of potential breach of confidence in relation to the teaching
of ethics.

I think what is missing from your account, from my perspective, is the
concept of members of OUR society being in this together. It is not
simply an issue which should be debated in the rather 'them-patients' and
'us-practitioners' manner you have taken.

The way forward is to include all stakeholders - otherwise it becomes a
rather 'bullylike' situation whereby those with the most power - ie in
this case through access to information disclosed in trust by uninformed
people, can overide the interests or rights of others.
In a civilised society I believe all should be treated with equal respect
and this places a responsibility on ethicists, etc. to inform the
uninformed as part of their work. In this case those such as researchers,
clinicians, ethicists etc. - 'know the score' and can protect their own
interests and indeed that of those in their wider social circle, by
deciding what they will or will not disclose. Therefore, the suggestion
that information should be used without the prior consent of those in the
vulnerable position - is unethical.

Perhaps ethicists and others might also think of using other parts of the
media in addition to specialist journals, which are to a great extent
still exclusive, to publish articles like this so that they will reach a
wider audience. Or perhaps advertise the Journal more widely. That it is
likely to generate more complexity should not be a reason to avoid wider
inclusion.

Although the article highlights the reaction of practitioners in the
medical profession to whistleblowers, I would point out that the same
bullying, stigmatising, undermining of the person's credibility, by for
example 'mentalising' or subtle or overt bullying and collusion - happens
to users of health services who have experienced unethical actions and to
those who have come across unethical resear...

Although the article highlights the reaction of practitioners in the
medical profession to whistleblowers, I would point out that the same
bullying, stigmatising, undermining of the person's credibility, by for
example 'mentalising' or subtle or overt bullying and collusion - happens
to users of health services who have experienced unethical actions and to
those who have come across unethical research and attempted to get their
concerns addressed.

Complaints systems in the past have too often failed those who have
attempted to highlight wrong doing. A significant problem has been that
the person has been positioned in the disadvantaged position of 'patient'
or 'client' rather than 'whistleblower'. Recently there is a definite
change in the way some Trusts and medical organisations are responding to
concerns. My reservation lies in that so often though what action is taken
depends on the ethical stance of those individuals in key positions.

Certain groups have suffered disproportionately when atempting to
speak out, for example those with mental health problems, and women who
raise concerns involving male practitioners.

In the 1980s I was involved with the initial stages of setting up an
organisation called POPAN. (The Prevention of Professional Abuse Network).
It dealt then with offences by therapists against clients but has now been
extended to cover abuse by all health and social care professionals. It is
now funded partly by the DoH and grants. In the early days the two
therapists who set up the organisation were slated and accused of
generating a problem which hardly existed.Some therapists in the NHS and
in influential positions in private organisations denied there was a
significant problem instead of investigating and working together with
POPAN.Some of their members were condemned as scare mongers, amongs other
offensive labels. Yet without especailly the courage of the two women
therapists who set up the organisation with no funding at all,from a
private flat in Hampstead, much of the abuse by professionals would still
be covered up.

I salute all those who have the courage to speak out and who will not
be silenced. The consequences can be very painful. Let us hope the winds
of change will keep on blowing.

As a bioethicist who works with and is a former board member of the
Canadian Down syndrome Society (CDSS)I was thankful that Julian Savulesque
noted the argument that "fetuses with Down's syndrome are 'devalued' and
that this represents discrimination.

The perspective of the CDSS is that Down is a condition and not a
disease. Persons with Down while different must be taken as equal members
of so...

As a bioethicist who works with and is a former board member of the
Canadian Down syndrome Society (CDSS)I was thankful that Julian Savulesque
noted the argument that "fetuses with Down's syndrome are 'devalued' and
that this represents discrimination.

The perspective of the CDSS is that Down is a condition and not a
disease. Persons with Down while different must be taken as equal members
of society, persons with specific and individual strengths and weaknesses.
To argue more generally a right to abort on the basis of their genetic
difference is to permit a eugenic pruning on the basis of incomplete
knowledge, and prejudice.

Down syndrome has always been in the forefront of the right against
genetic discrimination. It stands as a signal test case of the ease with
which ethicist and practitioners argue on the basis of parental choice for
selective abortion without considering the elements of social context that
may make parenting (or living with) a person of difference so challenging.
Thus I would argue that before considering the "right" for abortion on the
basis of genetic profile (sex, trisomy 21, 18, etc.) one must first addres
those elements that disadvantage to person who results.

These elements may include social prejudices (hence the location of
the example in India), social deprivation, limitations on social services
and support for persons of difference. If, as I and some others in the
"disability movement" argue, these are the critical factors involved in
such decisions then to not address them in this discourse is a grevious
failing and bad eugenics.

Finally, it is important to note that the issue of Down, and of a
fetuses choice, have greater resonance in the debate over persons of
difference generally. Assumptions concerning those with physically or
congitively restricted futures as a result of adult onset of disease
(Huntington Disease) or injury (spinal injury) are a transposition of this
concern to the greater field of disability studies.

Hopefully, in a future article these will all be addressed as a
singular critique of the assumptions that many bring to the simple
assumption that parental rights and utilitarian sense argue for selective
abortion, or among adults, termination, of those who are physically and
cognitively distinct.

Erin and Harris argue, as have others before them, for a regulated
market in human organs. The rationale is the imbalance between a limited
supply and growing demand for organs. Given that fact, and no others, it
makes "sense" to create a market that might increase supply.

The assumption of those who have argued this is that there are
neither risks nor dangers to donation and that the act of don...

Erin and Harris argue, as have others before them, for a regulated
market in human organs. The rationale is the imbalance between a limited
supply and growing demand for organs. Given that fact, and no others, it
makes "sense" to create a market that might increase supply.

The assumption of those who have argued this is that there are
neither risks nor dangers to donation and that the act of donation is
itself beneficent, and something to be encouraged. But living donors face
significant health risks both in surgery and post-operatively. These
include decreased function of the remaining organ, well-documented in the
case of living donors of a kidney, and those attendant generally on major
surgery.

As importantly, the work done by others on organ "donation"
internationally makes clear that there is a social inequality in these
"markets," one in which the poorest typically are convinced to donate and
sell, where money is returned, to the richestest. The work of Nancy Sheper
-Hughes is critical here, as is Locke's work generally.

More critically, and more generally, in many countries--the USA and
South AFrica being two I have studied--organ donation occurs within a
context of social and institutional inequality that assures a "free"
market will be biased against the poor and for the wealthy. In effect, it
may create a donor class, non-white and empoverished, for those who are
wealthier.

Indeed, as I have elsewhere argued, social inequalities in
healthcare, and in the graft organ distribution system, may exacerbate
existing organ shortages. Thus a market, however regulated, will likely be
inequitable and cause voluntary donations to diminish.

Before arguing for a market one therefore needs to consider the
structural inequalities in health care generally, and the graft organ
distribution specifically. Details of this argument, and data in support
for it, can be found in my text on the subject: Scarce Goods: Justice,
Fairness, and Organ Transplantation (Westport and London: Praeger Books,
2001). A list of papers detailing the research is listed on my website http://kochworks.com.

The Olivieri symposium offers an opportunity to reflect on
the Canadian regulatory climate and public governance. Baylis’ paper
raises a concern about the Canadian bio-ethics community’s collective
silence and stewardship regarding the Olivieri case.[1] A similar
collective silence greeted the recent McDonald report [2] on research
governance in Canada. The McDonald report assessed the integrity and
e...

The Olivieri symposium offers an opportunity to reflect on
the Canadian regulatory climate and public governance. Baylis’ paper
raises a concern about the Canadian bio-ethics community’s collective
silence and stewardship regarding the Olivieri case.[1] A similar
collective silence greeted the recent McDonald report [2] on research
governance in Canada. The McDonald report assessed the integrity and
effectiveness of research governance arrangements and concluded that
serious reform was required.

Curiously, while the McDonald report was recently referred to in a
Canadian Medical Association Journal (CMAJ) editorial as an example of
Canadian leadership,[3] it has never received an editorial commentary in
the CMAJ. Nor has any article in the CMAJ ever addressed the McDonald
report. Yet the CMAJ created an ethics editorship and a senior Canadian
bio-ethicist was chosen for the position in light of the growing
importance of ethics in public policy.[4] A chapter of the McDonald
report also focused on the mandate of the Canadian Medical Association and
the provincial colleges of physicians and surgeons and how research
governance issues are part of their ethics responsibilities.[5] Nor has
the McDonald report been discussed in Canadian law and health journals
except by its principal investigator.[6] One might expect a national
study on research governance that raises public concerns to warrant more
than occasional references. Unfortunately, the McDonald report is rapidly
approaching the status of a footnote. Its concerns included token public
representation in research governance, widespread institutional conflict
of interest, a regulatory system and culture that favors the research
community, and a narrow view of ethics that is funneled through research
interests and agendas that influence the thinking and practices of
researchers, research institutions and Research Ethics Boards (REBs), - -
the ethics watchdogs.

The McDonald report noted that REBs tend to focus narrowly on consent
forms; pay too little attention to benefits and harms for research
subjects; researchers consider ethics to be a matter of navigating through
the REB; and institutions see ethics as little more than the efficient
processing of research proposals.[7] Revelations of REBs violating
ethics guidelines at academic centers and teaching hospitals heighten the
McDonald report’s accountability concerns.[8] And while federal granting
agencies can withhold research funding from academic centers that fail to
comply with ethics guidelines, this has not occurred to date.[9]

In light of this regulatory climate, the question should be pressed
whether it makes good governance sense to enhance REBs powers along the
self-governing institutional lines DuVal proposes in the Olivieri
symposium.[10] His proposal puts more power in local REB hands by
extending their watchdog function to oversee contracts with sponsors.
Clearly, it is sensible for universities and hospitals to ensure that
contracts are in keeping with good ethics and the law. But for local REBs
to be the regulatory watchdog raises concerns about conflict of interest.
As Health Canada notes: “there may be serious conflict of interest on many
different levels: within REBs; between researchers and sponsors and within
research institutions”.[11] REBs are also steeped in a tradition of
secrecy. Transparency is a key feature of good public governance and
especially important for watchdog bodies in order to ensure public trust.[12] An open and independent watchdog that is at arms length from
research institutions would better serve the public good.

Against the backdrop of REB violations and accountability concerns
raised by the McDonald report, the question also arises whether increasing
the bio-ethics watchdog function would justify public confidence in the
kind of self-regulating model of governance adopted by the University of
Toronto.[13] It has been noted that many bio-ethics centres, including
the University of Toronto, receive corporate funding.[14] Concerns about
the ethics of marketing and the marketing of ethics to serve institutional
ends extend beyond corporate sponsorship. Universities, hospitals and
staff have become entrepreneurial and are producing, testing and taking
out patents on drugs and medical devices. Canadian research centres also
advertise to recruit research subjects through local papers which note
that “protocols have been approved by the Research Ethics Committee”.[15]
Given REB violations at academic centres and senior bio-ethicists’ silence
over the Olivieri case and the McDonald report, Singer et al may
overestimate how much moral rigor and power bio-ethicists can exercise in
their institutions as public watchdogs.

There is growing media and public interest in governance issues due
to major corporate scandals. Concerns about corporate governance mirror
issues raised by the McDonald report. How long will it take before the
Canadian media broadens its governance lens to include the research
regulatory culture? A broader discussion about good governance that is
actually beyond the Olivieri case needs to take place. Must we await loss
of public patience, or can we take charge of the reform process?

It may be most convenient to respond to Dr Andreae’s points[1] in turn:

1. Unless the claim that a child should determine its own genetic characteristics before it is conceived or born is intended to be flippant, it is logically incoherent. Conception is a decision that only a prospective parent can make. The editorial argument is that denial of choice of sex contributes to preventable maternal...

It may be most convenient to respond to Dr Andreae’s points[1] in turn:

1. Unless the claim that a child should determine its own genetic characteristics before it is conceived or born is intended to be flippant, it is logically incoherent. Conception is a decision that only a prospective parent can make. The editorial argument is that denial of choice of sex contributes to preventable maternal mortality and morbidity, particularly in developing countries. None of Dr. Andreae’s concerns addresses the ethics of tolerating the estimated daily toll of 1400 women, an estimated 515,000 women each year, who die of pregnancy-related causes, over 99% of whom are in developing countries of the world.[2] Many deaths are due to pregnancies that come too soon, too late, too often, and too closely spaced in women’s reproductive lives due to pressure to deliver sons.

2. The second point acknowledges that women’s lives are currently held hostage to multiple pregnancies to produce sons. Opposition to legal reform to relieve this burden tolerates exploitation of women’s vulnerability to repressive laws and policies. Ethical analysis in countries committed to justice between women and men increasingly leads to repeal or amendment of laws that repress women’s choices, to mitigate historic attitudes that treat individual women’s reproductive capacities as subject to public manipulation.

3. Willingness, reflected in point 2, to maintain women as instruments of state reproductive policies, even for benign purposes, is itself sexist, exploiting existing inequalities that deny women control over their reproductive options. Where son preference prevails, it is increasingly recognized that daughters must also be valued, not least to provide sons with wives and mothers of their children.

4. Apart from the inherent unreliability of slippery slope arguments as a basis for ethical public policies, extension of the argument for sex selection after birth of a first child to race is pragmatically unwarranted. There is demonstrable maternal mortality and morbidity where sex selection is denied; there is no evidence of the same related to denial of selection for family balancing on other grounds. Policy indicates that women should not be abandoned to preventable deaths to relieve any imagined speculative or theoretical concerns.

I am deeply worried about the guest editorial by Dickens.[1] Please see my comments below

Trying to dispel some of the counter arguments to sex selection, your argument of prospective parents’ autonomy is void. If anyone has a right to determine his or her sex, it would be the person concerned, in this case the unborn child. Surely, the parents will not have surrogate decision making pow...

I am deeply worried about the guest editorial by Dickens.[1] Please see my comments below

Trying to dispel some of the counter arguments to sex selection, your argument of prospective parents’ autonomy is void. If anyone has a right to determine his or her sex, it would be the person concerned, in this case the unborn child. Surely, the parents will not have surrogate decision making power in the absence of a dire need to make a choice, i.e. due to avoid hereditary sex related disease? Would the child be able to sue the parents for making a bad choice?

The threat of neglect or abuse a girl might face, should her ‘deselection’ not be permitted, amounts to hostage taking of the unborn life. Does the same not apply also to the burden a family or society may put on a woman, by forcing her into multiple pregnancies, until she delivers the desperately wanted son? What is more, the fact that a law might be ignored or disregarded, has rarely been an accepted argument for its repeal.

In fact, should promale sex selection become widespread in a already sexist society, this would most likely be a prerogative for the affluent and resourceful, reinforcing the existing inequality. Say predominantly male children would be born to privileged parents; they will provide them with more opportunity, leaving the other sex to grow up in even more disadvantaged circumstances.

But the slippery slope becomes most obvious if we imagine racially discordant couples wanting to determine their offspring’s race and color, be it based on (justified?) fears about societal abuse, neglect and disadvantage, or their wish to ‘balance their families’, or even only as a matter of taste...

In his article ‘Deafness, culture and choice’, Neil Levy argues that
‘the deaf will always be cut off from the buzz of conversation, always
restricted to a narrower range of jobs, always slightly alienated from the
mainstream of political, social, and cultural life.’[1]

He argues that deaf
children will always be somewhat worse off than hearing children, because
‘We are, in many ways, a logocen...

In his article ‘Deafness, culture and choice’, Neil Levy argues that
‘the deaf will always be cut off from the buzz of conversation, always
restricted to a narrower range of jobs, always slightly alienated from the
mainstream of political, social, and cultural life.’[1]

He argues that deaf
children will always be somewhat worse off than hearing children, because
‘We are, in many ways, a logocentric culture – one which is centred around
the voice’.
We can interpret this claim of Levy’s in two ways. One interpretation is
that Levy is making a practical argument that this logocentricity is so
ingrained that we can predict with certainty that it will always remain
central to our culture, and that deaf children will remain worse off. The
other is that Levy is making the claim that our culture is necessarily,
irrevocably logocentric.
Let us consider the latter argument first. Can this really be Levy’s
claim? It is not so hard to imagine a world without speech. Try walking
through your day mentally, replacing spoken language with sign language.
Replace telephones with videophones, and imagine teletext subtitles on
television shows. Wave and smile at your co-workers instead of saying
hello. Not only is such a world thoroughly possible, it is not obvious
that we would be substantially worse off. Some might argue that migrating
to sign-language would disadvantage the blind. Yet in the USA, there are
fewer people who have trouble reading, than those who have trouble hearing
conversation.[2] As a whole, then, our society might be better off if we
migrated to sign. Of course, it would require an enormously difficult and
painful change to migrate a hearing majority to a silent system of
language, and it is this practical difficulty which probably ensures that
such a migration will never happen.

We must assume, therefore, that it is the practical argument which
Levy is making. If this is Levy’s goal, then he means to show us that for
contingent practical reasons such as the difficulty of migrating to sign
language, we can reasonably predict that deaf children will always be
constrained by their deafness. It seems to me that this reasoning, if
anything, supports the central claim of the Deaf – that their deafness is
a constraint only because our society discriminates against those who
cannot hear.

The Deaf are not proposing that we should replace spoken language
with sign language, of course. Neither are they arguing that their
children will not be disadvantaged by being deaf. They are asking that it
be recognised that they are effectively disabled by the hearing majority,
not by some difference in their physiology, and that this distinction
means that if deaf children are worse off than hearing ones, it is because
of society’s discrimination, not because of the actions of the deaf
parents. This argument is not vulnerable to practical arguments like
Levy’s. If we continually discriminate against deaf people when we build
our telephones and engage in our spoken cultural, political and social
customs, then it certainly is through our discriminatory actions that they
are worse off; this fact is not affected by the difficulties we may face
in ridding our culture of its discriminatory structure.

I have yet to see an argument which faces up to the claims of the
Deaf. It seems to me that to establish that the deaf are not discriminated
against, or that the discrimination is not wrongful, we would need to show
that people whose physiology differs from the mainstream have no right of
equal access to our cultural, social, and political life. Perhaps this can
be shown, but I doubt it.

Utilitarian arguments might establish that the discrimination against
deaf people is outweighed by the difficulties involved in migrating the
mainstream to a deaf-friendly society, but they will never establish on
their own that this discrimination does not exist. If it does exist, then
it seems to me that the deaf ought to be allowed their claim that their
disadvantage is the fault of the selfish hearing population, and it does
follow from this that they should be allowed to have their deaf children,
while lamenting that the hearing majority has built a world that limits
the future of their child. After all, we do allow parents from other
minority groups to knowingly have children who will, like them, suffer
from discrimination.

I would suggest that a successful argument against having deaf
children would need to involve the claim that deaf children are worse off
in ways which cannot be changed, no matter what. These will not be social
reasons. Examples might be that deaf children will find it harder to avoid
oncoming trains, or that they will never experience the pleasure of
listening to the singing of whales. These limitations, whilst much less
grievous than the discriminatory social limitations, cannot be changed,
and therefore cannot constitute discrimination. Of course, it may be that
these minor limitations do not present us with enough reason to prevent
deaf parents from having deaf children.

In either case, it is certainly not enough to merely prove, as Levy
does, that deaf children will be worse off than hearing children. Deaf
parents know this, as do the parents of female children, black children,
poor children, and children of religious minorities. If we wish to deny
deaf parents their right to have deaf children, we must either dispute
their claim that they are wrongfully discriminated against, or show that
they are worse off in some necessary, irreparable way.

We thank Derek Narendra for his carefully considered response to our
recent article.[1] We are pleased that our work stimulated such a
thoughtful reply.

Narendra criticises our analysis on two major grounds. First, he
suggests that a survey such as ours cannot identify patients’ "considered
moral judgments," and therefore that the data are not valid for the
purpose we put them to. Second, he...

We thank Derek Narendra for his carefully considered response to our
recent article.[1] We are pleased that our work stimulated such a
thoughtful reply.

Narendra criticises our analysis on two major grounds. First, he
suggests that a survey such as ours cannot identify patients’ "considered
moral judgments," and therefore that the data are not valid for the
purpose we put them to. Second, he argues that, even if the data could
lead to valid empirical conclusions, it is not clear that these
conclusions should have any implications for normative theories of
bioethics.

As we articulated previously, the conceptual assumption behind our
empirical conclusions was that, "if patients value a dimension of care
highly, then problems in that dimension will increase the likelihood that
they will report negative overall evaluations of the hospital." Narendra
does not directly challenge this assumption, and he underestimates the
ability of patients’ reports to illuminate the patterns of value
structures that lie behind their first-order evaluations. Nevertheless,
he is right that no single study or method of analysis can fully capture
something so rich as "considered judgments." Our work is at best one
small piece of a puzzle by which investigators, using diverse
methodologies, might triangulate on patients’ deeply held views. Our
findings in isolation are less important than their consistency with those
obtained by other researchers using multiple different means.[2]

Narendra’s scepticism that patients’ views should have any
implications for normative bioethical theory raises a critical question
about the professional role of bioethicists: do they speak on behalf of
patients, of moral truth, or of some dynamic interplay between the two?
We favor the latter possibility, in which case we cannot understand how
ethicists might proceed in their work without listening to those they
claim to represent. It would be especially ironic if those who champion
respect for autonomy end up instructing patients, on the basis of first
principles, about how they ought to think or behave.

Contrary to Narendra’s interpretation, we did not link our empirical
findings to normative theory directly, by suggesting that providers are
morally obligated to act in ways that maximise patient satisfaction.
Rather, we argued that those things that substantially impact upon
evaluations of care are likely to be important (perhaps even morally
important) to patients, and should therefore be taken into account in
articulating normative models of health care relationships.

Finally, we do not see respect for persons and respect for autonomy
as independent and conflicting principles, but rather as closely related
and substantially overlapping sets of moral norms. In our view, respect
for persons has numerous dimensions in addition to the obligation to
respect autonomy. If so, and these dimensions are important to patients,
then they deserve greater conceptual and empirical attention than they
have heretofore received.

Differences aside, we agree with Narendra that "an exciting research
itinerary" at the interface of descriptive and normative ethics lies
ahead. We are flattered that, in his view, our work "takes us part of the
way down that path."